1. 1 Policy and programme lessons from the Multi-Country Evaluation (MCE) of IMCI The MCE Team

2. 2 Malnutrition 52%

3. 3 MCE Objectives  Document IMCI implementation  Measure IMCI impact on health and nutrition  Evaluate the cost-effectiveness of IMCI  Provide feedback to policy makers

4. 4 Major impact on child health and nutrition was expected at country level Improved health/nutrition Reduced mortality Improved household compliance/care Improved careseeking & utilization Improved quality of care in health facilities Improved preventive practices Training of health workers Health system improvements Family and community interventions Increased coverage for curative & preventive interventions Introduction of IMCI

5. 5 MCE in-depth studies Bangladesh: –efficacy RCT of 10 IMCI x 10 comparison areas Tanzania: –pre-post comparison of 2 IMCI x 2 comparison districts Brazil: –comparison of 32 IMCI x 32 comparison municipalities Uganda: –pre-post dose-response analysis of IMCI strength of implementation in 10 districts Peru: –as in Uganda, for 25 departments

6. 6 MCE step-wise approach Are adequate services being provided? at health facility level? at community level? Are these services being used by the population? Have adequate coverage levels been reached in the population? Is there an impact on health and nutrition?

7. 7 IMCI leads to improvements in health worker performance Source: Paryio G, Schellenberg J et al

8. 8 And can improve care quality at no extra cost Results from the Brazil MCE confirm that IMCI does not cost more than routine care

9. 9 Is IMCI being provided at health facility level? High training coverage has been reached in defined geographical areas Quality of training is usually good Difficulties in going to scale in relation to staff turnover and maintaining of quality of training Need for health systems support Drugs Supervision Referral District management skills

10. 10 Utilization is often too low to achieve impact through facility-based services alone % sick children who were taken first to a government facility Source: Arifeen S, Paryio G, Schellenberg J et al

11. 11 In Bangladesh, IMCI is associated with increases in health facility utilization Data source: MCE-Bangladesh, Routine MIS and GoB MIS But no other MCE site was able to replicate this effect……

12. 12 But coverage for key community interventions remains low in most countries Population coverage for key family practices Uganda MCE – 10 districts Source: Paryio G et al

13. 13 In Peru, facility and community IMCI were not implemented in the same departments Source: Huicho L et al Each dot represents one department Departmental coverage of IMCI-trained clinical and community workers (2003) Similar results in Tanzania

14. 14 Is IMCI being provided at community level? Implementation is spotty and uncoordinated with health worker training Community case-management interventions not included Community IMCI includes too many messages These findings have helped generate increased focus on the implementation of community component of IMCI

15. 15 Did IMCI have an impact on mortality?

16. 16 Tanzania: underfive mortality was 13% lower in the two IMCI districts Source: Schellenberg J et al Full IMCI in HF End of study 13% difference 95% CI: -7%, 30% Significant impact on stunting

17. 17 IMCI: No apparent impact in Peru r= 0.048 P= 0.824 Similar results in Brazil and Uganda

18. 18 Summing up (1) IMCI improves quality of care IMCI does not increase overall costs –Either for providers or out-of-pocket IMCI dramatically reduces cost per child managed correctly IMCI is the gold standard for facility care of children aged 7 days – 5 years

19. 19 IMCI can have an impact on mortality and nutrition But this requires: –Strengthening health systems –Reaching out to the community IMCI was least likely to be implemented well where it was needed most Summing up (2)

20. 20 What the MCE has contributed Feedback at national level Repositioning IMCI in the context of child survival by WHO and other agencies Lancet Child Survival Series + 30 papers Increased advocacy for child survival

21. 21 What the MCE has contributed The MCE showed that having interventions is not enough The real challenge is how to deliver these interventions to those who need them most

22. 22 IMCI and child health From MCE we know IMCI works in facilities! Requires adequate attention to health systems support and community coverage MCE was not able to evaluate the effectiveness of the community component of IMCI IMCI, as originally constructed, may not be the answer in every setting IMCI is evolving!

23. 23 Scaling up IMCI The Bangladesh experience Since these results first came out, IMCI has been scaled up to almost a fifth of Bangladesh, especially in high mortality areas Quality of training and performance outcomes have been maintained Initial focus on facility-based services, with increasing inclusion of health systems support and community interventions Shift from strategy to programme

24. 24 IMCI and child health IMCI CHILD HEALTH AND NUTRITION STRATEGY